Statutory Referral Form for SafeCare

Your referral and any subsequent contact will be confidential in order to protect your privacy. Information about our Privacy Policy is available upon request.

NOTE: Our Social Workers will endeavour to get in contact within 2 weeks of receiving your referral

Referrer Details:

Pronouns you would like us to use for you:(Required)
The cost of this programme is $5000 + GST. I confirm that funding is available for this referral:

Primary Parent / Caregiver

Other Parent / Caregiver

Pēpi / Tamariki

Are the parents / caregivers aware this referral has been made?(Required)
Custody Orders(Required)
Parenting Orders(Required)
Court Appointed Access(Required)
Protection Orders(Required)
Trespass Orders(Required)
Are there Parenting Concerns(Required)
Please Include any care and protection concerns
Is the Whānau currently involved with Oranga Tamariki?(Required)
Has the Whānau previously been involved with Oranga Tamariki?(Required)
Has the Whānau used Home & Family services in the past?(Required)
Has the Whānau experienced family violence?(Required)
Are there concerns regarding mental health for the Whānau?(Required)
Is there other relevant information for us to be aware of, including safety/legal issues?(Required)
Will a parenting assessment be required?(Required)

Other Whanau / Caregivers / Professionals / Agencies Involved:

Home & Family Charitable Trust PO BOX 287 Christchurch e: contact@homeandfamily.net.nz web: www.homeandfamily.net.nz